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Healthy Families, Healthy Environment

Kristen P. Patterson, Smita Gaith, and Jason Bremner

November 11-12, 2013 | Addis Ababa, Ethiopia

Thanks to Rachel Yavinsky for her review and input.

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The second international Population, Health, and Environment Conference, organized by the Population Reference Bureau and the PHE Ethiopia Consortium, convened in Addis Ababa, Ethiopia in November 2013 around the theme “Healthy Families, Healthy Environment.”

Population, health, and environment (PHE) initiatives use an integrated, rights-based approach to achieve sustainable development by improving access to health services, especially family planning and reproductive health (FP/RH), while also helping communities improve livelihoods, manage natural resources, and conserve critical ecosystems.

The conference, funded by the David and Lucille Packard Foundation, USAID’s Office of

Population and Reproductive Health, and USAID’s East Africa Regional Office, brought together over 150 participants representing 20 different countries in sub-Saharan Africa, Asia, Central America, Europe, and North America.

This policy brief shares key conference outcomes on implementation best practices; monitoring and evaluation; networking, advocacy, and media communication; and expanding and

institutionalizing PHE interventions. The brief outlines needs, priorities, and ways that PHE implementers and advocates can capitalize on the conference to increase interest in and support of PHE integration.

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Conference Objectives

The conference built on existing momentum in the PHE community and developed strategies for scaling up efforts to address the priorities of remote and rural communities where poor

reproductive health outcomes and population growth exist hand-in-hand with poverty and unsustainable natural resource use. Conference objectives were:

1. Create a space for sharing and networking among PHE implementers.

2. Raise the profile of PHE efforts to increase interest among new donors and possible implementers.

3. Identify needs and priorities for PHE advocates and implementers to chart future technical assistance and support.

Maturation of the PHE Approach

The PHE field has expanded since the last international PHE conference held in Addis Ababa in November 2007. That conference focused on assessing the state of and potential for a PHE approach to sustainable development in East Africa, as well as building PHE implementers’ skills related to media communications, advocacy, and project design and evaluation. Since then, remarkable progress has been made in PHE in East Africa.

The 2013 gathering revealed how much had changed. While the 2007 conference was largely planned by external organizations and donors, over half of the 2013 Conference Steering Committee members were from developing countries, exhibiting the growth of PHE thought-leaders from developing countries.

Panel sessions during the conference featured 20 PHE projects at the field-level in 12 different countries. Policy efforts and measuring results were central themes. Participants embraced the complexity of a PHE approach, reported on innovative partnerships, and engaged in

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Implementation Best Practices

“Where the environment is most fragile, so are women’s health and rights.”

Karen Dubois, FUNDAECO Guatemala

PHE projects must be women-centered. Experience has shown that projects that put women

at the center of PHE efforts have greater impact because FP/RH services are a central component of PHE. Projects that work with women to assess and address their reproductive health challenges, as well as the broader factors contributing to these challenges, have had great success. Examples include: developing a gender-based violence component; developing a woman-to-woman peer education component; and working on micro-credit with women’s groups as a complement to FP/RH services. Each of these examples grew out of discussions with women about the barriers they faced to better lives and improved reproductive health. These projects have put the poor status of women at the center of PHE efforts, rather than population. In the long-term, better reproductive health, lower fertility, and slower population growth will benefit women and their communities.

Working with local leaders to design project activities builds trust and ownership. One

emerging best practice is to facilitate interaction among communities, local leaders, and regional governments during the project design and goal-setting phase. Many PHE projects work with existing health systems and agricultural extension workers, as well as local government institutions. Involving these groups in the project-design phase has led to more support from and better coordination with local governments and ultimately, program success. Projects such as the Ethiopia Wetlands and Natural Resources Association have collaborated closely with local government officials and technical staff, trained existing community-based workers as PHE providers and peer educators who delivered integrated PHE messages to community members, and collaborated closely with community health extension workers and agricultural extension agents. Many of these local leaders and partners have become the best advocates for PHE and, in several cases, leaders from neighboring areas have learned about the PHE approach through their local government peers and requested scale-up to their areas.

PHE projects use multidisciplinary partnerships to achieve better results. PHE

implementers embrace the complexity of work across sectors and forge new partnerships to overcome challenges. For example, climate vulnerability assessments have been used to

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develop PHE project strategies in Tuungane (a collaboration of Pathfinder International, The Nature Conservancy, and Frankfurt Zoological Society). Similarly, Conservation International in Madagascar partnered with two local partners, Voahary Salama and Ny Tanintsika, to add FP/RH services and water, sanitation, and hygiene services to conservation activities in high biodiversity and critical freshwater ecosystems. These types of partnerships, though they require additional up-front investments in cross-sector training and coordination, allow PHE projects to broaden their approach.

Availability of and access to contraceptives is essential as PHE projects build demand for family planning. Close alignment between the project, community stakeholders, and

local/district government health systems ensures sufficient contraceptive supplies are available to meet the demand. Many projects work through existing structures (improving them when necessary) and coordinate with existing health care providers and community health workers. These projects help the existing health system reach harder-to-reach individuals, sustain

contact between providers and contraceptive users, and decrease the barriers to use. In several instances in remote areas, where contraceptive supply can be a great challenge and is costly, several projects have successfully built their own health systems (health clinics outside of the government clinic structure) to reach those who have almost no access to family planning, and have increased rates of use dramatically.

Male involvement in the health decisions of the household fosters healthy behaviors.

Projects engage men and reach a broader audience with PHE and sexual and reproductive health messages by discussing sexual and reproductive health with community associations such as fisheries cooperatives, community beach management units, farmer’s associations, and youth clubs. Some projects have shown that efforts to engage men can build male support for contraceptive use by their partners. In addition, environmental education to promote PHE messages focuses on the next generation and encourages young men to talk about reproductive health and learn about healthy behaviors.

Monitoring and Evaluation (M&E) - Challenges and Recommendations

One challenge for PHE projects is the ability to measure and attribute results to PHE integration. The lack of evidence from PHE projects is a barrier to investments by donors and other large organizations. At the conference several important M&E lessons emerged from projects:

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Recommendation 1: Conduct thorough baseline research prior to project implementation and develop a strong theory of change so that project focus areas and measures of success are carefully selected.

Baseline surveys can include a rapid needs assessment and a period of time to hear and gather community ideas to feed the project design. Baseline information gives the project a starting point for the measures of success or indicators to target. Many development projects struggle with good M&E, and it is especially challenging for PHE because of the cross-cutting nature of projects and the scale of household behavior and environmental resources.

Recommendation 2: Partner strategically with organizations with sector-specific M&E experience.

The capacity for M&E remains a challenge for many small organizations that have the community connections to implement an integrated PHE approach. Partnerships can help overcome some of these capacity limitations. One such partnership, between Conservation Through Public Health (CTPH) and FHI360, helped CTPH, a small conservation-focused organization, to overcome their limited M&E capacity for health interventions. FHI360 provided technical assistance that led to an updated logic model, revised indicators, updated data

collection tools, and a comprehensive database. This partnership demonstrated the importance of leveraging the expertise of strong partners from individual sectors in a PHE project.

Similar partnerships between universities and PHE implementing organizations in Ethiopia, Madagascar, and elsewhere are also underway. For example, in Ethiopia, PHE implementers are partnering with academia to evaluate the “invisible” changes that may result from PHE projects, specifically whether integrated interventions lead to changes in beneficiaries understanding and appreciation of the linkages between population, health, and the environment.

Recommendation 3: Ensure data are multidimensional, including gendered aspects, with both quantitative and qualitative methods to capture PHE’s added value.

Measuring the added value of the integration of the PHE approach is a challenge for

implementers and advocates. Participants made several recommendations to overcome this challenge. Baseline, monitoring, and evaluation data should consider how PHE projects affect men and women differently, in terms of resources used, community decisionmaking, and

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gender-sensitive indicators that allow for tracking of these differences. Implementers should use qualitative methods, including participatory rural analysis and policy stakeholder mapping, to assess the added value of PHE efforts and policy advocacy results that are often overlooked or not easily captured in quantitative surveys.

Qualitative process evaluation interviews of the project staff, partners, and key stakeholder can be used to assess how a program is implemented, describe novel elements of the intervention, identify elements best suited for replication, and establish a foundation for quantitative

evaluation. Process evaluation research contributes to the PHE evidence base by generating detailed case studies of integrated PHE programs, specifically explaining strategies

organizations used for implementation; which components were most successful; what efficiencies staff, partners, and stakeholders perceive; what challenges they confront due to integration; and the extent to which sectors are integrated across the project.

Networking, Advocacy, and Media Communications

“PHE can be part of the solution to create positive associations around population and sustainable development goals!”

Karen Newman, Population and Sustainability Network

From Madagascar to the Philippines to Ethiopia, PHE networks have served as a prominent method of advocating for and advancing cross-sectoral programming. Well-run networks with clear governance structures that are endorsed (not simply legalized) by the government can create solidarity and provide a unified voice to support practice-to-policy dialogue at multiple levels, from the field to national and international conferences. For example, the PHE community has a critical, time-bound opportunity to advocate for the inclusion of population dynamics and environmental sustainability in the international- and national-level discourse on the post-2015 Sustainable Development Goals (SDGs) currently under development. PHE implementers can be persuasive advocates for an integrated approach to the SDGs and create positive associations around population dynamics and sustainable development.

Participants emphasized the value of a network for cooperation and coordination; knowledge management (sharing tools, identifying and disseminating best practices); facilitation of capacity building for its members; and connecting members with other PHE networks, the media,

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policymakers, and learning opportunities. Participants highlighted several important factors essential for networks to thrive.

Foremost is a commitment of member organizations to shared values. Participants stressed the importance of networks not competing with their members for funds, as this can lessen trust and collaboration. It is also important to pay a coordinator who can serve as a host to international visitors, facilitate visits to member institutions’ project sites, and act as a constant presence in the capital for communication and advocacy with policymakers and the media.

In addition, networks need clear action plans with time-bound objectives to maintain forward momentum. Many PHE networks are learning how to identify clear, targeted advocacy and communication actions, and where efforts should be focused. The paid coordinator can provide the follow-up needed for progress in meeting the action plan.

Public sector buy-in and leadership are also critical, since the public-sector members can be the voices for policy advocacy from within the government. The current PHE networks have varied levels of public sector involvement and leadership. Some are steered by the public sector while others have not had much public sector participation and are seeking to boost public sector involvement. Finding the right balance is a challenge specific to each country.

PHE networks must clearly and effectively explain activities and impacts, especially those related to communications and advocacy. The benefits of a PHE approach and the details of integrated projects can be difficult to portray because of its conceptual complexity and cross-sectoral nature.

PHE networks can overcome complexity by coordinating and improving communication. Advocates and implementers need to make key points clear, distill statements into simple messages, selectively summarize, and be responsive to information requests. Networks with good communications can ensure that PHE avoids controversial messages about population control.

When communicating with the media, PHE implementers and advocates can set clear goals for media engagement as part of a project’s strategic plan, and strive for a balance between paying for media coverage versus developing a relationship with the media to increase coverage based

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on the desired return on investment of time and money. Engaging local media and providing project updates, similar to engaging policymakers, is a way to stay in touch and be visible. Media training can help PHE implementers better understand the differences between advocacy and opinion journalism versus objective or mainstream journalism and the norms within different countries. Social media and the internet are changing established media norms, providing benefits such as greater access to youth, and drawbacks like oversimplification of complex messages. Finally, PHE may do well to bring well-known voices to the table as advocates and supporters in the media.

Expanding and Institutionalizing PHE Interventions

“Scaling up is not a technical task as much as an organizational, managerial, and policy/political task.”

Ados May, Implementing Best Practices Secretariat and ExpandNet member

In order to move beyond the project-by-project paradigm and the pilot nature that plagues PHE projects, several recommendations were made. Meaningful links must be made to advance national-level policies and build bridges with other sustainable development communities of practice. PHE projects must design projects with scale-up in mind from the beginning. One way to scale up the adoption of the PHE approach through policy change is to advocate that integrated solutions to population and environment challenges be identified within national-level development strategic plans. For example, the governments of Kenya and Malawi see rapid population growth as a barrier to economic development and environmental stability within population, economic, and environmental policies. Yet, the provision and delivery of family planning services is entirely sectoral and left to the Ministry of Health, which has insufficient support to meet existing need. The PHE approach can be presented as a means for different sectors to support the efforts to extend family planning services if it is identified within existing development plans. Prioritizing adequate funding for implementation of integrated solutions within development plans could institutionalize PHE as a sustainable development approach and result in scale-up.

The adoption of PHE by regional associations such as the Lake Victoria Basin Commission (LVBC) represents an opportunity for scale-up. The LVBC supports PHE networks to provide

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technical guidance and explore PHE implementation with their partners. The LVBC works from within the East Africa Commission (EAC) to advocate for the EAC to recognize PHE as a promising approach. Furthermore, LVBC can advocate to other associations, such as the Lake Tanganyika Authority or the Nile River Basin Commission, to promote PHE as well.

Opportunities exist for the PHE community to collaborate with the resilience and climate change communities, which are looking at environmental change and community response, to

demonstrate the benefits that PHE integration can provide. For example, environment and health are included in conceptual frameworks of resilience: Drawing parallels between PHE and resilience could position PHE as a strategy in work on resilience and climate change. The potential exists to explore how PHE addresses gender and other social dimensions, as well as conflict and security. To date, most PHE projects have not used resilience and vulnerability assessment tools. Further connections with these communities will require more robust monitoring and evaluation using the tools accepted by the resilience community.

The publication, Beginning with the End in Mind, was developed by the organization ExpandNet to help organizations deliberately increase the impact of their work over time by planning for scale-up during project design. While primarily created for health and development use, it can be adapted for PHE projects. Planning for scale-up entails involving future implementers from the outset to build ownership, increase chances of sustainability, and limit complexity (which would inhibit later scale-up). For scale-up to be sustainable, both vertical (political, policy,

institutional, and legal) and horizontal (expansion and replication) plans need to be included. For example, because community-based distribution of family planning products is difficult to sustain without project-based funding, PHE programs should investigate working with the local public and private sector delivery systems at the start of a project. HoPE-LBV provides another example, as initially the project planned for agro-forestry interventions to be implemented primarily by project personnel with communities in model households. After group analysis, implementers realized that agro-forestry interventions needed to be implemented jointly with village environmental committees, subcounty environment officials, district environmental officers, and community members in order to allow for future scale-up and sustainability. Several questions remain unanswered after scale-up discussions and are important for future consideration by the PHE community. These include:

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• Is the name “PHE” a problem, due to decades-old concerns over coercive policies associated with the word “population” as well as the exclusion of key PHE strategies such as livelihoods from the acronym?

• How can PHE become a central program of large conservation and health organizations, rather than a small part of their work that is rarely highlighted?

• Is lack of additional donor support the principle constraint to scale-up?

The Way Forward: Needs and Priorities

“When people are not healthy, they cannot engage adequately in agricultural interventions, earn less from their activities, and remain very poor.”

Christine Kaaya Nakimwero, VEDCO Uganda

Lester Couthino of the Packard Foundation encouraged the PHE community to look at the next frontier of PHE work and position PHE as a way of supporting gender, reproductive, land, and property rights for women who have traditionally been denied control. For example, in the Gambia, turning environmental stewardship exclusively over to women led to the creation of a sustainable shellfishery and improved livelihoods. Control over decisionmaking regarding their livelihoods and personal health care led one woman to declare after participating in the PHE project, “We have reached grade 12; we will not go back to grade 1.”

PHE efforts should continue to focus on Africa given the amount of momentum, donor interest in family planning, and growing experience of implementers. One way to build on this momentum is to develop new partnerships and bring new organizations focused on health, the environment, and livelihoods in Africa to the PHE approach. One suggestion was for donors to invest in a centralized funding framework that encourages new partnerships both among donors who have different sector priorities but understand the importance of the integration, and among

implementing agencies that bring varying expertise.

In addition, PHE implementers should continue to bolster the limited evidence base for PHE by increasing partnerships with organizations that can assist with research and evaluation.

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impacts. Bringing together the PHE and research communities to think creatively about ways to overcome measurement challenges is a priority action.

Together these actions, along with the additional recommendations mentioned, chart a path for future investments in the PHE approach by donors and partners. The energy of the conference made it clear that the PHE approach is entering a new phase as results are generated. Today’s PHE efforts have great momentum, excellent tools, and new partners with new opportunities. The future for PHE across Africa and internationally is great. The conference built the resolve of participants to transform the combined energy into progress.

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BOX 1. PHE Approach Highlighted at International Conference on Family Planning (ICFP)

PHE programs stood out at the ICFP: Two side events, two round tables, five poster

presentations, and six panels with PHE content were included at the three-day conference in Addis Ababa, immediately following the PHE Conference. These events reached a much broader audience than the traditional PHE community: Family planning advocates and programmers, journalists, donors, and researchers were among the over 3,300 participants from 120 countries.

At the close of the ICFP, a prestigious EXCELL award was given to Blue Ventures, a conservation organization that has been implementing PHE since 2006. The award

recognized Blue Ventures for their innovative work to address unmet need for family planning in remote western coastal Madagascar: The contraceptive prevalence rate increased from 10 percent in 2007 to 55 percent in 2013. The recognition of PHE as a valid approach for

reaching the hardest-to-reach shone a spotlight on Blue Ventures and the PHE community, echoing the ICFP theme of “Full Access, Full Choice.”

Source: Laura Robson, Caroline Savitzky, and Vik Mohan, “Results From Six Years of

Integrating Family Planning With Marine Conservation in Southwest Madagascar,” presentation, Population, Health, and Environment Conference, Addis Ababa, Ethiopia, November 11-12, 2013.

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BOX 2. Recent PHE Monitoring and Evaluation Results

An assessment after 10 years of PHE interventions found that, compared to a nearby village, young people in the PHE intervention village differed in how they utilized natural resources: The PHE villagers were more involved in forest management and practiced less clearing of the forest than their counterparts who had not been exposed to the PHE project.

A pilot partnership between a tree-planting organization and a family planning project tested the effectiveness of training established community-based “green volunteers” on family planning and PHE. An evaluation showed 81 percent of the green volunteers were knowledgeable about family planning and PHE.

Evaluations found that integrating family planning with a program in a nonhealth

development sector (microfinance, agriculture, and environment) is feasible, acceptable, and effective.

Sources: Abebe Demisu Belay, “Integration of FP/SRH With Forest Conservation Enhanced

Active Involvement of Young People,” presentation, Population, Health, and Environment Conference, Addis Ababa, Ethiopia, November 11-12, 2013; and Caroline Mackenzie et al., "Population, Health, and Environment Activities Conducted by the Green Belt Movement in Kenya: Results of a Pilot Introduction," presentation, Population, Health, and Environment Conference, Addis Ababa, Ethiopia, November 11-12, 2013.

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